Clinical Judgement Test 1 - Yoost Chapters 4-9 & 20

Questions and Answers

Which action would the nurse undertake first when beginning to formulate a patient's plan of care?

Identify realistic outcome indicators

Rank patient concerns from assessment data (correct)

List possible treatment options

Consult with health care team members

Which resource is most helpful when prioritizing identified nursing diagnoses?

Maslow's hierarchy of needs (correct)

Nursing Outcomes Classification (NOC)

Gordon's functional health patterns

Nursing Interventions Classification (NIC)

If a patient is exhibiting signs and symptoms of each of the following nursing diagnoses, which should the nurse address first while planning care?

Knowledge Deficit

Acute Pain (correct)

Fatigue

Body Image Disturbance

Which statement illustrates a characteristic of goals within the care planning process?

Long-term goals are helpful in judging a patient's progress. Signup and view all the answers

If the nurse chooses the Nursing Outcome Classification (NOC), Appetite (1014) for a chemotherapy patient, which outcome indicators would be acceptable for evaluation of goal attainment? (Select all that apply.)

Expressed desire to eat Signup and view all the answers

Which action by the nurse would be most important in developing a patient-centered plan of care for an alert, oriented adult?

Listening to the patient's concerns and beliefs about proposed treatment Signup and view all the answers

Which intervention can the nurse initiate independently while providing patient care? (Select all that apply.)

Applying heel protectors Signup and view all the answers

The nurse notices that a patient is becoming short of breath and anxious. Which of the following interventions is a dependent nursing action, requiring the order of a primary care provider?

Administering oxygen by nasal cannula Signup and view all the answers

Which situation indicates the greatest need for collaborative interventions provided by several health care team members?

Hospice referral Signup and view all the answers

The Nursing Interventions Classification (NIC) index is used for what purpose in the planning step?

Provides guidance for selection of nursing interventions Signup and view all the answers

The Nursing Outcomes Classification (NOC) is used for what purpose in the planning step?

Provide the list of standardized nursing sensitive outcome indicators Signup and view all the answers

Prioritization of nursing diagnoses requires the use of which of the following tools?

Maslow's hierarchy of needs Signup and view all the answers

Inclusion of the patient in the planning process is significant due to the fact that

Inclusion of the patient in the planning increases chances of goal attainment. Signup and view all the answers

The charge nurse of a cardiac unit running code situation is practicing what type of planning?

Acute patient planning Signup and view all the answers

The nurse working in the patient discharge center is practicing what type of planning?

Discharge patient planning Signup and view all the answers

Identify physician-initiated interventions:

Administer antibiotic intravenously twice a day. Signup and view all the answers

The nurse has provided home care instructions to the mother of a child who is being discharged after cardiac surgery. Which statement by the mother indicates a need for further instruction?

We are going to her cousin's birthday party tomorrow! The whole family will be there! Signup and view all the answers

Outcome indicators are

Criteria by which goal attainment is observed or measured. Signup and view all the answers

Goals are set during the planning step and (Select all that apply.)

Are broad statements of purpose that describe the aim of nursing care. Signup and view all the answers

Standards of care guide practice through (Select all that apply.)

Accountability. Signup and view all the answers

Identify nurse-initiated interventions: (Select all that apply.)

Ordering heel protectors for patients susceptible to skin breakdown Signup and view all the answers

Identify the situation where collaborative interventions could be implemented: (Select all that apply.)

Palliative care Signup and view all the answers

What should the nurse consider before implementation of all nursing interventions? (Select all that apply.)

Scope of nursing practice Signup and view all the answers

The nurse facilitates the use of the intellectual standard of critical thinking of significance by posing which question to determine the patient's understanding of his or her new diagnosis of type 1 diabetes mellitus on his or her lifestyle?

Do you understand how to administer your insulin? Signup and view all the answers

In providing care to a newly admitted patient, the nurse's inferences are more accurate if based upon which of the following?

Objective data Signup and view all the answers

During the postoperative assessment on a patient, the nurse has a 'hunch' that the patient has a postoperative complication based upon?

Intuition Signup and view all the answers

In using intuition to address a clinical problem, the expert nurse bases his or her approach upon which of the following?

Experiential knowledge Signup and view all the answers

A new graduate nurse explains a new approach in the positioning of patients with chronic low back pain. The nurse preceptor responds, 'That is not the way we do it here.' The preceptor's response illustrates which error in critical thinking?

Bias Signup and view all the answers

In preparing to administer medications to a patient, the nurse notes a medication that she has never administered. If the nurse administers the medication without researching the medication, this represents which error in critical thinking?

Lack of information Signup and view all the answers

In preparing for a certification examination, the nurse chooses to develop a concept map to help understand the content. This strategy is based upon which characteristics of concept maps? (Select all that apply.)

Organizes visual data Signup and view all the answers

What term best describes the nature of the nursing process?

Dynamic Signup and view all the answers

A disoriented patient is admitted to the hospital accompanied by his spouse. From whom should the nurse collect subjective data on this patient?

The patient's wife Signup and view all the answers

Prior to identifying accurate nursing diagnoses, what action must be taken by the nurse?

Clustering related patient data Signup and view all the answers

A nurse admits a 5-year-old female to the postanesthesia unit following a tonsillectomy. The child is crying. What should be the nurse's first action?

Assess the child to determine why she is crying. Signup and view all the answers

Which statement is a correctly written example of an actual nursing diagnosis?

Activity intolerance related to imbalance between oxygen supply and demand as evidenced by dyspnea on exertion and significant drop of oxygen saturation from 98% to 88% with activity Signup and view all the answers

Which long-term goal is written correctly?

Patient will remain afebrile throughout hospitalization. Signup and view all the answers

What phrase best describes the essence of critical thinking?

Seeking solutions to problems Signup and view all the answers

Which body is responsible for defining and disseminating information on nursing diagnoses?

North American Nursing Diagnosis Association International Signup and view all the answers

The statement 'ongoing collection of data' best describes which phase of the nursing process?

Assessment Signup and view all the answers

Which statement illustrates the most measurable outcome indicator?

Demonstrates dressing change Signup and view all the answers

What should be the focus of all nursing interventions?

Providing patient-centered care Signup and view all the answers

Which action should the nurse take 30 minutes after administering oral pain medication to a patient?

Evaluate the effectiveness of the administered pain medication. Signup and view all the answers

Which piece of assessment data may be accurately obtained during the observation phase?

Presence of body odor Signup and view all the answers

Patients from which generation would be most comfortable with the nurse using electronic resources for health screening?

Millennials Signup and view all the answers

Which type of question would be best for the nurse to use when trying to determine the extent of a patient's knowledge concerning a disease process?

Open ended Signup and view all the answers

Which statement by the nurse best describes health history assessment?

Collection of health history information is ongoing and methodical throughout patient interaction. Signup and view all the answers

Which statement illustrates appropriate documentation following palpation?

Abdomen soft, non-tender without distention Signup and view all the answers

What type of assessment is most appropriate for a patient newly admitted to the hospital for intermittent loss of vision in the left eye?

Complete Signup and view all the answers

Which statement is the best example of subjective, secondary data?

Patient complains of extreme fatigue and dizziness when walking in the room. Signup and view all the answers

A patient is admitted to the nursing unit with numbness and tingling in the right hand, pain in the cervical spine, and occasional loss of consciousness. Into which functional health pattern would the nurse organize this data?

Cognition and perception Signup and view all the answers

Which information gathered during assessment is considered to be subjective data?

The patient indicates pain and burning are present when urinating. Signup and view all the answers

The most important source in data collection is/are?

The patient Signup and view all the answers

Which action(s) should the nurse take during the termination phase of the patient interview? (Select all that apply.)

Validate information covered with the patient. Signup and view all the answers

What is the most important reason for nurses to use a standardized taxonomy such as NANDA-I?

Patient safety Signup and view all the answers

Which nursing diagnosis is appropriately written? (Select all that apply.)

Chronic Pain related to osteoarthritis as manifested by verbalized postoperative discomfort. Signup and view all the answers

Which phrase best represents a related factor in an actual nursing diagnosis?

Ineffective adaptation to recent loss Signup and view all the answers

Which action does the nurse need to take before determining the type(s) of nursing diagnoses that are applicable to a patient? (Select all that apply.)

Thoroughly review the patient's medical history Signup and view all the answers

What is the primary difference between a risk nursing diagnosis and an actual nursing diagnosis?

Defining characteristics are not part of a risk diagnosis. Signup and view all the answers

What is the most important action for a nurse to take in order to have a new nursing diagnosis considered for inclusion in the NANDA-I taxonomy?

Provide evidence-based research to support nursing care Signup and view all the answers

What is the most significant problem that may result from improperly written nursing diagnostic statements?

Lack of direction for formulating patient plans of care Signup and view all the answers

Which statement best describes the relationship of medical diagnoses and nursing diagnoses?

Medical diagnoses may be interrelated to nursing diagnoses. Signup and view all the answers

A patient has just experienced a cardiac arrest on the unit. The nurse has implemented the acute care plan for management of code situations. What is the next step the nurse should take?

Perform the steps of the nursing process related to the patient's current condition. Signup and view all the answers

What signs and symptoms would the nurse appropriately cluster for a patient with extreme anxiety? (Select all that apply.)

Patient states, 'I feel nervous all the time, especially when I am alone.' Signup and view all the answers

The hospice nurse believes the nursing diagnosis chronic sorrow is significant in the recovery process of patients recently experiencing a loss. What is required to support the addition of new nursing diagnoses to the NANDA-I taxonomy?

Clinical research and data collection Signup and view all the answers

The nurse has just received a postoperative patient to the floor post-ureteral stone manipulation. Choose the priority nursing diagnosis.

Risk for urinary retention r/t general anesthesia and trauma to ureter Signup and view all the answers

The relationship of the medical diagnosis to the nursing diagnosis is?

The medical and nursing diagnoses should complement each other. Signup and view all the answers

An example of implementation of evidence-based practice by the nurse would be the nurse?

Initiates a new policy protocol for the removal of c-collars and bed board restraints of the emergency department patient based on empirical research results. Signup and view all the answers

The clustering of data is significant to the nursing diagnoses step because clustering of data will?

Group the data of similar problems and aid in accurate nursing diagnosis identification. Signup and view all the answers

Study Notes

Clinical Judgement and Nursing Process

Critical thinking involves assessing the impact of medical diagnoses on nursing actions.
Accurate nursing inferences are primarily based on objective data.
Intuition in nursing aids in recognizing complications during assessments.

Nursing Diagnoses

Identifying related factors enhances understanding of nursing diagnoses.
Nursing diagnoses must be correctly written to guide effective patient care planning.
Differentiating between actual nursing diagnoses and risk diagnoses is crucial for appropriate interventions.

Patient Assessment

Ongoing data collection is essential and is part of the assessment phase.
Subjective data often comes directly from patient reports of symptoms or experiences.
Health assessments should be thorough, systematic, and continuous throughout patient interactions.

Goals and Outcomes

Clear, measurable goals are necessary to evaluate patient progress effectively.
Both long-term and short-term goals should be specific and time-bound.
Active participation and expressions of desire from patients suggest engagement in their care process.

Effective Communication

During patient interviews, open-ended questions yield more comprehensive patient insights.
Validating and summarizing information received enhances the clarity and accuracy of data collected.

Importance of Evidence-Based Practice

Implementing evidence-based protocols ensures patient safety and enhances care quality.
The nursing process requires collaboration with a healthcare team to develop comprehensive care plans based on assessment findings.

Prioritization in Nursing Care

Acute and severe symptoms, such as pain, should take precedence in care planning.
Use of resources like Maslow's hierarchy can facilitate sound prioritization of nursing diagnoses.

Documentation Standards

Documentation must be clear and accurate to reflect observations and patient interactions properly.
Utilizing standardized nursing terminology is essential to maintain clarity and consistency in nursing practice.

Challenges in Nursing Judgment

Errors in critical thinking can arise from biases, lack of information, or illogical assumptions.
Continuous education and awareness of personal biases improve critical thinking in nursing practice.

Models and Classification Systems

Nursing interventions and outcomes are standardized using specific classification systems (NIC, NOC).
Familiarity with these systems aids in the identification and evaluation of nursing actions and patient responses.### Patient-Centered Care
Crucial to listen to a patient's concerns and beliefs when developing a care plan.
Collaborating with social workers can help identify resources for patient support.
Involving family and friends enhances the care process and provides a broader support network.
Providing written care options aids in informed decision-making for patients and families.

Independent Nursing Interventions

Nurses can independently auscultate lung sounds, monitor skin integrity, and apply heel protectors.
Ordering blood transfusions and adjusting antibiotic dosages require physician orders.

Dependent Nursing Actions

Administering oxygen requires an order from a primary care provider.
Assessing oxygen saturation and evaluating peripheral circulation are independent actions.

Collaborative Interventions

Hospice referrals signify the need for collaborative care from various health care professionals.
Teamwork is essential for complex patient needs.

Nursing Intervention Classifications

NIC index guides nursing interventions selection based on specific diagnoses.
Regular updates ensure the accuracy of nursing interventions listed in NIC.

Nursing Outcomes Classification

NOC provides standardized indicators for assessing nursing-sensitive outcomes.
Useful in determining the appropriateness of goals for implementation.

Prioritization Tools

Maslow's Hierarchy of Needs assists in prioritizing nursing diagnoses based on patient needs.
The ABCs (airway, breathing, circulation) are fundamental in assessing and prioritizing care.

Patient Inclusion in Planning

Involving patients in planning increases the likelihood of achieving health goals.
Patient-driven goal setting is essential for effective care.

Types of Nursing Planning

Acute planning focuses on immediate patient needs, especially during critical situations.
Discharge planning prepares patients for post-hospitalization care and recovery.

Physician-Initiated vs. Nurse-Initiated Interventions

Administering antibiotics is a physician-initiated intervention.
Nurse-initiated interventions can include preadmission teaching and modifying care plans based on assessments.

Home Care Instructions

Parents need thorough understanding to ensure proper post-operative care for children.
Statements indicating misunderstanding of discharge instructions necessitate further education.

Outcome Indicators

Measurable criteria that evaluate whether goals set during the planning phase were achieved.
Broader statements reflect nursing diagnoses and inform practice quality.

Goals in Nursing Care

Goals are broad statements outlining the aims of nursing care and can be both short-term and long-term.
Clearly defined, realistic, and measurable goals foster effective nursing practice.

Standards of Care

Standards direct nursing practice through prudes and accountability.
They help in creating comprehensive patient care plans.

Nurse-Initiated Interventions

Ordering protective devices and conducting education sessions are within the nurse's scope of practice.
Collaborating with social workers enriches the patient's support systems.

Situations for Collaborative Interventions

Implementing interventions for physical therapy, home health care, and palliative care require collaboration.
Surgical procedures typically involve a distinct set of professionals and are less about collaboration.

Considerations Before Nursing Interventions

Address potential communication barriers and cultural practices to ensure effective care.
Understanding the scope of nursing practice is essential before implementing interventions.
Assessing the patient’s functional status is crucial for tailored care.

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Prepare for your Clinical Judgement Test with this quiz covering Chapters 4-9 and 20 from the Yoost textbook. Each question is designed to reinforce your understanding and readiness for the exam. Flashcards will help you recall essential definitions and concepts.